title: Optimized guidance of percutaneous edge-to edge repair of the mitral valve using real-time 3-D transesophageal echocardiography.
abstract: BACKGROUND
  Percutaneous edge-to-edge repair with the MitraClip device has been shown to allow effective treatment of mitral regurgitation. It is mainly guided by transesophageal echocardiography while fluoroscopic guidance is of less importance. The impact of real-time three-dimensional transesophageal echocardiography (RT 3-D TEE) for guidance of this complex interventional procedure has not been evaluated.
  
  
  METHODS
  In 28 high-surgical risk patients with moderate or severe mitral regurgitation (mean age 67 ± 10 years; 15 male), 2-D and RT 3-D TEE were used for the guidance of percutaneous edge-to-edge mitral valve repair using the MitraClip device. We performed a structured analysis to compare information and guidance capacity provided by RT 3-D TEE compared to 2-D TEE.
  
  
  RESULTS
  RT 3-D TEE was found to provide advantages in 9 of 11 steps of the percutaneous mitral repair procedure. The advantages related to optimized definition of the transseptal puncture site, improved guidance of the clip delivery system towards the mitral valve, precise positioning of the clip delivery system simultaneously in anterior-posterior and lateral-medial direction above the mitral valve considering mitral valve scallops A2 and P2 and valvular regurgitation jet position, adjustment of the opened clip-arms perpendicular to the commissural line, visualization of the clip position relative to the valvular orifice and of the remaining regurgitant jet after clip closure from atrial as well as ventricular views providing double orifice images and thereby allowing confirmation or rejection of clip position in medial-lateral direction. RT 3-D TEE was inferior to 2-D TEE for leaflet grasping and analysis of leaflet insertion.
  
  
  CONCLUSIONS
  In complex interventional edge-to-edge repair with the MitraClip device requiring optimal spatial information RT 3-D TEE allows improved guidance of the procedure. RT 3-D TEE guidance compared with 2-D TEE guidance alone resulted in greater operator confidence to adequately perform the procedure.
authors.affiliation: Medical Clinic I, University RWTH Aachen, Pauwelsstraße 30, 52057, Aachen, Germany.
authors.forename: Ertunc
authors.initials: E
authors.lastname: Altiok
authors.forename: Michael
authors.initials: M
authors.lastname: Becker
authors.forename: Sandra
authors.initials: S
authors.lastname: Hamada
authors.forename: Sebastian
authors.initials: S
authors.lastname: Reith
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Marx
authors.forename: Rainer
authors.initials: R
authors.lastname: Hoffmann
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000295:instrumentation*; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D011446:Prospective Studies; D013525:Surgical Instruments